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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.12 Governing Body was out of compliance.

A-0049 The governing body must: Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. Based on document review and interviews, the facility's governing body failed to ensure the medical staff adhered to the Medical Staff Bylaws requirement for a peer review process, the purpose being to hold the medical staff accountable for providing quality care to patients.

Based on document review and interviews, the facility's governing body failed to ensure the medical staff adhered to the Medical Staff Bylaws requirement for a peer review process, the purpose being to hold the medical staff accountable for providing quality care to patients. (Cross-reference A-0347)

Findings include:

Facility policy:

The Hospital Governing Body policy read, the Board of Directors is the governing body. The Executive Vice President of the Hospital (hospital VP) is the person appointed by the Board responsible for the day-to-day operations.

References:

According to the facility's Bylaws, the powers and responsibilities of the Board of Directors include: to establish an effective mechanism for considering and acting upon Medical Staff reports of medical care evaluation activities; to assure compliance with (and otherwise adhere to) policies and procedures, adopted by the Parent Corporation.

According to the Medical Staff Bylaws, each member of the Medical Staff and each physician exercising Clinical Privileges shall continuously meet all of the following responsibilities: Actively participate in and regularly cooperate with other members of the Medical Staff in discussion and decision making related to patient care, including but not limited to, peer review, utilization management, budgetary priorities, quality assessment and improvement, and related monitoring activities and in discharging such other functions as may be required by the Medical Staff from time to time.

The Medical Staff shall: Participate in and evaluate the effectiveness of patient care monitoring and utilization management activities; maintain surveillance over the completeness, timeliness, and clinical pertinence of patient medical records;

By applying for Medical Staff membership or reappointment, or Clinical Privileges, each applicant: Consents to participation in the ongoing peer review and quality assessment processes at the Hospital, understands that an effective peer review and quality assessment process may necessitate consideration of information that may otherwise be of a confidential nature pertaining to activities at other hospitals or health care entities, authorizes the Hospital to seek or provide such information when appropriate, and agrees to hold any other hospital or health care entity, including their staff, employees, and representatives harmless for providing or requesting such information.

1. The governing body failed to ensure the medical staff had a peer review process in place to assess the quality of care provided by the medical staff.

a. According to the facility's Bylaws, the powers and responsibilities of the Board of Directors included: to establish an effective mechanism for considering and acting upon Medical Staff reports of medical care evaluation activities; to assure compliance with (and otherwise adhere to) policies and procedures, adopted by the Parent Corporation.

b. On 4/18/23 at 10:43 a.m., an interview with the senior vice president of the facility (VP) #7 was conducted. VP #7 stated he also acted as the facility's chief executive officer (CEO) and was part of the governing body. VP #7 verified there was no formal peer review process in place for the routine review of the care provided by the medical staff. VP #7 explained work was being done towards implementing a peer review process to provide oversight of patient care, however, the process was not fully developed. VP #7 stated it was a priority for the facility to focus on continuous quality improvement with the medical staff rather than the current reactive approach taken by the facility, which was to review medical records for medical staff oversight only when a negative outcome occurred.

VP #7's interview was in contrast with the facility's Bylaws, which documented the responsibilities of the Board of Directors to include establishing an effective mechanism for considering and acting upon Medical Staff reports of medical care evaluation activities and assuring compliance and adherence to policies and procedures.

c. Interviews with the medical director (Director) #5 were conducted on 4/17/23 at 2:01 p.m. and on 4/18/23 at 8:30 a.m. Director #5 stated he began the role of medical director at the end of March of 2023. Director #5 explained peer review processes consisted of medical record reviews conducted by a person of the same discipline as the provider being reviewed. Director #5 further explained the review included assessing for complete documentation and reviewing the patient's condition to determine if there was a positive response to the treatment provided. Director #5 stated implementing a peer review process was important because a peer would understand the elements needed for assessing a provider's level of care more than a nurse or a staff member in administration. Director #5 stated not having a peer review process in place could result in negative patient medical outcomes including patients receiving substandard care.

Director #5 stated there was no peer review process as outlined in the Bylaws currently in place to evaluate the quality of care provided when he assumed the role of medical director. Director #5 stated the current process for identifying medical staff performance issues consisted of reviewing critical incident reports involving medical staff that were forwarded to him from the quality department.

d. On 4/18/23 at 10:15 a.m., an interview was conducted with the chief medical officer (CMO) #6. CMO #6 stated he was the prior medical director from September of 2022 until Director #5 took over the position in March of 2023. CMO #6 stated a peer review process was important in order for medical staff to receive feedback for professional development. CMO #6 stated prior to his arrival as medical director, there was a peer review process in place, however, the facility moved away from the peer review process due to improvements needed to be made with the process. CMO #6 stated a peer review process was being created and that there was not a current medical record review process in place for medical staff to review the quality of care provided to patients.

The interviews were in contrast with the Medical Staff Bylaws which read, each physician exercising clinical privileges shall actively participate in and regularly cooperate with other members of the medical staff in discussion and decision making related to patient care including participating in peer review.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 Quality Assessment and Performance Improvement Program was out of compliance.

A-0286 The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors. The hospital must measure, analyze, and track adverse patient events. Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Based on interviews and document review, the facility failed to ensure incidents were investigated according to the timeframe identified by facility leadership and preventative measures were implemented to prevent reoccurrence. Specifically, interventions were identified to prevent reoccurrence, however, the facility failed to implement the new processes and interventions. Additionally, the facility failed to ensure implemented actions were monitored to ensure the improvement was sustainable.

Based on document review and interviews, the facility failed to ensure incidents were investigated according to the timeframe identified by facility leadership and preventative measures were implemented to prevent recurrence. Specifically, interventions were identified to prevent recurrence, however, the facility failed to implement the new processes and interventions. Additionally, the facility failed to ensure implemented actions were monitored to ensure the improvement was sustainable.

Findings include:

Facility policies:

The Compliance Oversight of Quality Programs and Clinical Integrity read, the quality program is structured in accordance with the Medical Bylaws and the Quality Assurance Performance Improvement (QAPI) Plan. The quality improvement committee (QIC) bears primary responsibility for monitoring, maintaining and improving quality processes. Clinical audits include coding review of psychiatric services, peer review, objective chart review of medical necessity by the medical records department and ongoing charting audits. Inpatient psychiatry services are also subject to peer review, as described by the Medical Bylaws.

The Quality and Safety Improvement Program policy read, the purpose is to establish the parameters of the facility's quality and safety performance improvement program. Provides guidelines for collecting and analyzing data to identify, address and monitor performance to continually improve the quality of care.

The governing body is responsible for setting priorities and identifying the frequency of data collection. The medical staff is responsible for providing oversight in the process of analyzing and improving hospital performance. The quality improvement manager collaborates with senior leadership to manage the completion of all mandatory reporting and investigations of quality of care concerns and critical incidents. The QIC is responsible for developing, implementing, and monitoring the performance improvement program. The Critical Incident Review Committee is responsible for reviewing trends on all critical incident reports (CIRs) and completing case reviews.

The Quality Assessment and Performance Improvement (QAPI) Plan policy read, the Board of Governors (Board) has overall responsibility for the quality of patient care including the safety of patients. The Board also holds the medical staff accountable for quality of patient care.

The Critical Incident Reporting policy read, the purpose is to comply with mandated reporting to State and Federal regulatory agencies. All staff are responsible for incident reporting. Critical incident/patient safety event is an event, incident, near miss or condition that could have resulted or did result in harm.

Every critical incident will be reviewed by the Quality Improvement Manager to determine if it meets criteria for mandatory reporting. All incident reporting, investigation and reviews will be documented as a part of the critical incident. All adverse events and critical incidents will be reviewed through the quality of care concern process as outlined.

Reference:

The Mental Health Worker (MHW) meeting minutes from 3/27/23 read, All staff working as a 1:1 are required to remain awake throughout the shift. Staff must always be arm's length from the patients. Staff members on 1:1s may not leave the patient without being relieved first.

1. The facility failed to ensure preventative measures were implemented to prevent recurrence for a patient with numerous self harm events.

I. Review of Patient #14's medical record and patient events revealed the facility did not implement interventions in order to prevent the recurrence of self-harm.

a. A review of Patient #14's medical record from 3/14/23 to 4/15/23 revealed Patient #14 was admitted to the adolescent unit on 3/14/23 for an attempted overdose of Lithium (a mood stabilizing medication). Patient #14 was placed on a 1:1 observation (one staff member providing constant and direct observation to one patient) due to self-harm behaviors, primarily from scratching herself and inflicting wounds. The order further instructed that the patient may have required 2:1 observation (two staff members providing constant direct observation to one patient) at night due to excessive acts of self harm. There was no documentation the staff implemented the 2:1 observations outlined in the order above.

b. Despite the patient being monitored by the staff on a 1:1 observation, Patient #14 was documented to have 13 incidents of self-harm during her stay. Review of patient safety events for Patient #14 revealed the following incidents of self harm:

i. On 3/15/23 at 6:15 a.m., Patient #14 self-harmed herself by scratching her face and until she bled. The patient was not responsive to redirection.

Action items from the patient safety event report were as follows: Facility leadership to include the director of nursing (DON) #3, the assistant director of nursing (ADON) #4, and the director of quality (Director) #2 completed a chart review and purchased safety mitts to be utilized as an intervention. According to the medical record, a provider order was placed for the mitts to be applied if needed on 3/27/23, 12 days after the incident on 3/15/23.

ii. On 3/15/23 at 9:00 p.m., a code gray was called because the patient was scratching her face and neck.

Action items from the patient safety event report were as follows: On 3/17/23 DON #3 and ADON #4 completed a chart review for documentation.

iii. On 3/16/23 at 8:30 p.m. Patient #14 self harmed by turning away from staff and picking at her face which caused it to bleed.

Action items from the patient safety report were as follows: On 3/20/23 quality director (Director) #2 reviewed the chart. The director noted a 'danger to self active treatment plan' was initiated on 3/16/23.

iv. On 3/18/23 Patient #14 had self-harmed her hip under the blankets causing a small abrasion.

Action items from the patient safety report were as follows: Director #2 completed a chart review on 3/20/23. The case review, summary, and conclusion documented that a treatment plan was in place for danger to self on 3/16/23; the patient was redirected and staff provided a boundary that the blanket would be removed if the patient cannot stop self harming; the incident was noted in nursing note; The patient was on 1:1 enhanced observation. Director #2 determined the intervention was appropriate for the patient's behavior.

v. On 3/19/23 at 4:00 p.m., Patient #14 was noted to throw herself on the floor to self harm. The patient was then noted to be triggered by a peer and began to self harm. At 5:00 p.m., Patient #14 required restraint until 5:35 p.m.

vi. On 3/20/23 Patient #14 told the RN at 9:00 a.m. the patient began to self harm with a broken bead she found in the activities room. The new wound was located on the patient's throat.

At 2:00 p.m., Patient #14 began to self harm by scratching her forearm creating a new wound.

At 3:30 p.m., Patient #14 began punching a wall. The patient was then transferred to another facility for a medical evaluation.

Action items from the patient safety reports on 3/19/23 and 3/20/23 were as follows: On 3/23/23 a multidisciplinary team meeting was held and the following items were discussed to be implemented: mental health based workbooks, prompted journaling, self affirmations, school work needing completion, increased individualized therapy, meditation and relaxation techniques, and giving praise.

A review of Patient #14's medical record revealed a lack of consistent implementation of the identified interventions.

vii. On 3/25/23 at 7:30 a.m., the day shift staff member noticed blood on Patient #14's pillowcase and blanket. Patient #14 stated the staff member who was her 1:1 overnight was not watching her, so Patient #14 self-harmed herself all night.

Action items for the patient safety report were as follows: On 3/26/23 a review of the event was assigned to DON #3, ADON #4, Director #2, the Mental Health Worker (MHW) supervisor and additional leadership to complete an investigation. It was identified that the staff member assigned to be the patient's 1:1 had not completed their orientation packet prior to working on that unit. Re-education was to be provided to the MHWs at the 3/27/23 meeting on the expectations while working as a 1:1. On 3/27/23 the director of quality notified police and completed a full investigation report and chart reviews. On 3/29/23 The treatment plan for the patient was to be updated with the mitts being ordered for bedtime. Additionally, on 3/29/23 DON #3 was assigned the task to implement an hourly rounding process.

There was no evidence beyond re-education that a mechanism was put into place to ensure staff assigned as 1:1s were observing the patient appropriately in order to prevent the recurrence of the event.

Also, there was no evidence in the medical record of the implementation of an hourly rounding process.

In addition, there was no evidence of the mitts being consistently attempted or used to deter self-harming behavior.

viii. On 4/4/23 at 8:46 p.m., Patient #14 began escalating and self harming by hitting, scratching, and biting herself. Patient #14 was assisted to the floor by two staff members due to the patient sliding out of her chair. She then began banging her head on the floor. A code gray was called at 8:58 p.m.

Action items for the patient safety report were as follows: On 4/5/23 a member of the quality department was assigned to review the patient's chart.

According to an interview with Director #2 on 4/13/23 at 11:26 a.m., the chart review had not been completed.

ix. On 4/5/23 at 7:50 p.m., A code gray was called due to Patient #14 banging her head on the wall and scratching and digging at her arms.

Action items for this patient safety report were as follows: On 4/7/23 the case management coordinator was assigned to go to the patient's unit to check in with staff on the patient's current care plan. Additionally, on 4/7/23, a chart review was assigned to be completed. A review completed by the quality department and facility leadership committee revealed there was not any mention of the patient's mitts being used in prior CIRs.

x. On 4/6/23 at 9:45 p.m., Patient #14 was in her room and began scratching herself. Staff attempted to verbally de-escalate the patient but was not successful. Staff went hands-on and moved Patient #14's hands away to prevent her from harming herself. Mitts were utilized for approximately 45 minutes.

Action items for this patient safety report were as follows: The use of the patient's mitts was successful. On 4/7/23 a chart review was assigned to be completed.

As of 4/11/23 there was no evidence a chart review had been completed in response to this patient safety event.

xi. On 4/8/23 at 7:30 a.m. an MHW alerted the RN to Patient #14 having new scratches. When the RN assessed Patient #14, there were multiple wounds on her arms and one on her right thigh. Patient #14 stated the staff member assigned as her 1:1 the night before had watched her do this and did not stop her.

Action items for this patient safety report were as follows: There was no evidence of an investigation or preventative actions implemented as of 4/11/23.

c. On 4/13/23 at 11:26 a.m., an interview with Director #2 was conducted. Director #2 stated when patient safety events were investigated the goal was for events to be reviewed within seven days. Patient #14's patient events were discussed with Director #2. Director #2 stated she was unaware of the current status of the nurse rounding process and referred to the director of nursing (DON) for further information.

d. On 4/17/23 at 3:02 p.m., an interview was conducted with the interim DON #3. DON #3's review of Patient #14's event was discussed. DON #3 stated the process for RNs to conduct hourly rounding had not been implemented due to technology issues, however, RNs were told to round more frequently. DON #3 stated at the time of the interview, there was no process in place to show evidence of the RN rounding. DON #3 stated the MHWs at the facility seemed to be inexperienced and the initial training they received seemed to be ineffective.

2. The facility failed to ensure a patient safety event was investigated according to the facility's decided timeframe in order to implement preventative measures and prevent recurrence.

I. A review of Patient #18's medical record and interviews conducted revealed the facility failed to complete an investigation of a patient safety event within the time frame identified by facility leadership and evaluate implemented measures in order to evaluate if the measures were successful.

a. On 3/5/23 Patient #18 was admitted for suicidal ideation (SI). On 3/6/23 the patient's history and physical note revealed the patient reported chronic diarrhea.

Further review of Patient #18's medical record revealed the following:

i. On 3/10/23 the patient reported to have abdominal discomfort.

ii. On 3/11/23 the patient complained of diarrhea.

iii. On 3/12/23 the patient reported nausea, vomiting, and diarrhea. Orders were placed for the patient to have Gatorade for dehydration.

According to the Provider's Note on 3/12/23, the medical team was following the patient for the patient's diarrhea, however, there was not a medical consult or provider note in the patient's medical record until 3/17/23.

On 3/12/23 at 10:18 a.m., seven days after the patient was admitted, Loperamide (a medication provided to treat diarrhea) 2 mg was ordered to be administered to the patient every four hours as needed for diarrhea. Additionally, a probiotic was ordered for the patient to receive daily.

The medication administration record revealed the patient received three doses of the medication on 3/12/23, four doses on 3/13/23, and two doses on 3/14/23.

iv. On 3/13/23 the patient reported vomiting and diarrhea however staff observed the patient's stool to be formed.

v. On 3/14/23 the RN noted the patient to have frequent loose stools.

vi. On 3/15/23, ten days after the patient was admitted, labs for a complete blood count (CBC) (a count of blood cells in the body) and a complete metabolic panel (CMP) (tests different substances in the blood, such as electrolytes) were ordered and collected. A stool sample was ordered as well. Additionally, staff noted the patient continued to have diarrhea.

vii. On 3/16/23, the RN noted the patient had diarrhea eight times throughout the shift. Additionally, a urine sodium sample was ordered as well as a lipid sample.

viii. On 3/17/23, the patient continued to experience diarrhea. A medical consult note read, the patient's labs resulted with a low sodium level of 129 and recommended the medication Effexor (a medication used to treat depression) be discontinued since there was a possibility this was contributing to the patient's hyponatremia (low sodium level in the blood).

This medical consult note was written 11 days after Patient #18 initially reported chronic diarrhea.

ix. On 3/18/23 the patient was noted to have eight to ten episodes of loose stools.

b. Review of a patient event report revealed the following: On 3/19/23, Patient #18 was observed wandering the halls all night and asking for water. The patient had begun collecting cups from anywhere she could find them and was noted to have as many as 20 cups in her possession. She was observed drinking several cups of water including three cups alone during her medical assessment. Patient #18 was manic and constantly moving. The patient was observed repeatedly clenching her jaws and panting. Her blood pressure (BP) was high at 180/90 when it was assessed by the provider and her blood sugar was above normal measuring 152. She was noted to be disoriented but cooperative and she had frequent diarrhea, nausea, and vomiting which had not resolved with medications. She was then sent out for medical evaluation at an outside facility.

When Patient #18 arrived at the outside facility, Patient #18 suffered from hyponatremia (low sodium) with a sodium level of 107 and hypovolemia (decreased volume of fluid in the body). Additionally, during the patient's admission at the outside facility, Patient #18 experienced two seizures due to her severe hyponatremia.

i. According to the follow-up documentation to the patient safety event, a chart review was completed by the quality director on 3/20/23. The chart was also assigned to be reviewed by the medical director on 3/20/23. Further review revealed the medical director did not review the patient's chart until 4/7/23, which was 19 days after Patient #18 was transferred out of the facility to receive medical care. The medical director identified the following gaps: medical care was delayed and nursing staff did not enter a consultation for a medical provider to evaluate the patient into the log book. Additionally, the patient reported diarrhea upon admission and labs were not collected.

Additional gaps were identified by the facility which included a delay in medical care, labs were not collected upon admission though the patient was experiencing symptoms of hyponatremia (low sodium), and the patient's medical complaints were not given appropriate attention.

ii. On 3/31/23 the facility noted an apparent cause analysis (ACA) was to be conducted with clinical staff on 4/13/23.

Review of supporting documents revealed a case conference was conducted with the medical director, two nurse practitioners, the DON, the ADON and two quality team members on 4/13/23, 25 days after Patient #18 was transferred out to another facility for medical treatment.

iii. Review of the nursing education provided on 4/11/23 revealed nursing staff were re-educated on the need to use the medical consult log book when a patient needed to be seen by the medical team.

There was no evidence the facility implemented monitoring to ensure the re-education provided to nursing staff to use the medical log was successful to ensure patients who exhibited medical symptoms were evaluated by a medical provider. This was in contrast to facility policy and the QAPI plan, which read, the quality committee was responsible to monitor and maintain quality processes to continually improve the quality of care.

c. On 4/17/23 at 3:02 p.m., an interview was conducted with DON #3. DON #3 stated there was not a set timeline for events to be investigated and it typically depended on the severity of the incident.

DON #3 stated there was an ongoing concern related to communication issues and nursing staff utilizing the medical log to monitor patients who exhibited acute and chronic medical conditions. DON #3 stated the RNs were re-educated on using the log, however, he was unsure if the log or process was being audited to ensure the re-education was sustained.

d. On 4/13/23 at 11:26 a.m., an interview with the director of quality (Director) #2 was conducted. Director #2 stated when an incident report was received, a quick high level review was completed by the quality team and then the event was assigned to other supervisors or leaders for review. Director #2 stated the goal was for an investigation to be completed within seven days, however, the time frame was not delineated in a policy.

e. On 4/17/23 at 1:38 p.m., an interview was conducted with the assistant director of nursing (ADON) #4. ADON #4 stated she sometimes reviewed charts associated with patient events and assisted in the investigation. ADON #4 stated she tried to have her investigations completed within seven days of the event. ADON #4 stated it was important to review patient safety events and implement process changes in order to decrease risks to patients and ensure patients were safe.

f. On 4/17/23 at 2:03 p.m., an interview was conducted with the medical director (Director) #5. Director #5 stated he would attend critical incident report (CIR) meetings and would review issues that involved concerns with providers. Director #5 stated he was responsible for reviewing the quality of care provided to patients. Director #5 stated it was important to complete the investigation as soon as possible in order to prevent the recurrence of similar incidents.

The interviews were in contrast to the follow-up documented for the patient safety event involving Patient #18, as the investigation of the event and review of the patient's chart to identify gaps in care by the medical director did not occur until 19 days after the patient required transfer to receive medical care.

Additionally, the facility did not ensure implemented preventative measures to prevent recurrence were monitored to ensure they were successful in preventing recurrence of patient safety events.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.22 Medical Staff was out of compliance.

A-0347 The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. The medical staff must be organized in a manner approved by the governing body. If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: An individual doctor of medicine or osteopathy; a doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located; a doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. Based on document review and interviews, the facility failed to ensure the medical staff was organized in accordance with facility policies and the Medical Staff Bylaws to evaluate the quality of care provided to patients at the facility.

Based on document review and interviews, the facility failed to ensure the medical staff was organized in accordance with facility policies and the Medical Staff Bylaws to evaluate the quality of care provided to patients at the facility. (Cross-reference A-0049)

Findings include:

Facility policies:

The Hospital Medical Staff policy read, Medical staff are accountable to the Board for the quality of care provided to patients.

The Compliance Oversight of Quality Programs and Clinical Integrity policy read, the quality program is structured in accordance with the Medical Bylaws and the Quality Assurance Performance Improvement (QAPI) Plan. The quality improvement committee (QIC) bears primary responsibility for monitoring, maintaining, and improving quality processes. Clinical audits include coding review of psychiatric services, peer review, objective chart review of medical necessity by the medical records department, and ongoing charting audits. Inpatient psychiatry services are also subject to peer review, as described by the Medical Bylaws.

Reference:

According to the Medical Staff Bylaws, each member of the Medical Staff and each physician exercising Clinical Privileges shall continuously meet all of the following responsibilities: Actively participate in and regularly cooperate with other members of the Medical Staff in discussion and decision making related to patient care, including but not limited to, peer review, utilization management, budgetary priorities, quality assessment and improvement, and related monitoring activities and in discharging such other functions as may be required by the Medical Staff from time to time.

The Medical Staff shall: Participate in and evaluate the effectiveness of patient care monitoring and utilization management activities; maintain surveillance over the completeness, timeliness, and clinical pertinence of patient medical records;

By applying for Medical Staff membership or reappointment, or Clinical Privileges, each applicant: Consents to participation in the ongoing peer review and quality assessment processes at the Hospital, understands that an effective peer review and quality assessment process may necessitate consideration of information that may otherwise be of a confidential nature pertaining to activities at other hospitals or health care entities, authorizes the Hospital to seek or provide such information when appropriate, and agrees to hold any other hospital or health care entity, including their staff, employees, and representatives harmless for providing or requesting such information.

1. The medical staff failed to implement a process to proactively assess the quality of care provided at the facility by providers.

a. On 4/18/23 at 9:46 a.m., an interview with family nurse practitioner (FNP) #8 was conducted. FNP #8 stated she had not been involved in a peer review process of reviewing medical records to assess the quality of care provided.

b. On 4/12/23 at 10:03 a.m. and 11:26 a.m., an interview with the director of quality (Director) #2 was conducted. Director #2 stated there was no system in place in the quality department for reviewing medical records to monitor the performance of medical staff. Director #2 further stated she was unaware of a peer review process implemented by the medical staff for reviewing medical records to evaluate the quality of care.

c. Interviews with the medical director (Director) #5 were conducted on 4/17/23 at 2:01 p.m. and on 4/18/23 at 8:30 a.m. Director #5 stated he began the role of medical director at the end of March of 2023. Director #5 explained a peer review process consisted of medical record reviews conducted by a person of the same discipline as the provider being reviewed. Director #5 further explained the review included assessing for complete documentation and reviewing the patient's condition to determine if there was a positive response to the treatment provided. Director #5 stated implementing a peer review process was important because a peer would understand the elements needed for assessing a provider's level of care more than a nurse or a staff member in administration. Director #5 stated the risk of not having a peer review process in place included patients receiving substandard care which could result in negative patient medical outcomes.

Director #5 stated there was no peer review process in place to evaluate the quality of care provided when he assumed the role of medical director. Director #5 stated the current process for identifying medical staff performance issues consisted of reviewing critical incident reports involving medical staff that were forwarded to him from the quality department.

d. On 4/18/23 at 10:15 a.m., an interview was conducted with the chief medical officer (CMO) #6. CMO #6 stated he was the prior medical director from September of 2022 until Director #5 took over the position in March of 2023. CMO #6 stated prior to his arrival as medical director, there was a peer review process in place, however, the facility moved away from the peer review process due to improvements needing to be made with the process. CMO #6 stated a peer review process was in the process of being created and that there was not a current medical record review process in place for medical staff to review the quality of care provided to patients. CMO #6 stated a peer review process was important in order for medical staff to receive feedback for professional development.

The interviews were in contrast with the Medical Staff Bylaws, which read each member of the medical staff was responsible for participating in a peer review process.